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Bar N, Firestone RS, Usmani SZ. Aiming for the cure in myeloma: Putting our best foot forward. Blood Rev 2023; 62:101116. [PMID: 37596172 DOI: 10.1016/j.blre.2023.101116] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 08/20/2023]
Abstract
Frontline therapy for multiple myeloma (MM) is evolving to include novel combinations that can achieve unprecedented deep response rates. Several treatment strategies exist, varying in induction regimen composition, use of transplant and or consolidation and maintenance. In this sea of different treatment permutations, the overarching theme is the powerful prognostic factors of disease risk and achievement of minimal residual disease (MRD) negativity. MM has significant inter-patient variability that requires treatment to be individualized. Risk-adapted and response-adapted strategies which are increasingly being explored to define the extent and duration of therapy, and eventually aim for functional curability. In addition, with T-cell redirection therapies rapidly revolutionizing myeloma treatments, the current standard of care for myeloma will change. This review analyzes the current relevant literature in upfront therapy for fit myeloma patients and provides suggestions for treatment approach while novel clinical trials are maturing.
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Affiliation(s)
- Noffar Bar
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine University, New Haven, CT, USA.
| | - Ross S Firestone
- Multiple Myeloma Service, Department of medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Saad Z Usmani
- Multiple Myeloma Service, Department of medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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2
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Nair CK. Pretransplant Determinants of Outcome in Patients with Myeloma Undergoing Autologous Transplantation in Lower Resource Settings. EUROPEAN MEDICAL JOURNAL 2021. [DOI: 10.33590/emj/20-00263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The treatment landscape in multiple myeloma has significantly changed since the introduction of high-dose melphalan with autologous stem cell rescue in the 1980s. Many randomised controlled trials have clearly demonstrated the superiority of autologous stem cell transplantation in improving survival compared to conventional chemotherapy. However, outcomes in myeloma are highly variable with median survival as short as 2 years and as long as 10 years or more. The main adverse factor predicting shorter survival is presence of high-risk cytogenetics. However, there are many other potential factors that can contribute to the treatment outcomes. This review looks at the various pretransplant variables that are associated with post-transplant outcomes in myeloma.
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Affiliation(s)
- Chandran K Nair
- Department of Clinical Haematology and Medical Oncology, Malabar Cancer Centre, Thalassery, Kerala, India
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3
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Liu JR, Li J, Huang XJ. [Problems and progress of autologous hematopoietic stem cell transplantation in multiple myeloma]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:82-86. [PMID: 33677876 PMCID: PMC7957257 DOI: 10.3760/cma.j.issn.0253-2727.2021.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Indexed: 12/22/2022]
Affiliation(s)
- J R Liu
- Department of Hematology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - J Li
- Department of Hematology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
| | - X J Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
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4
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Jiang N, Wang L, Xiang X, Li Z, Chiew EKH, Koo YM, Lee HS, Lin HP, Tan AM, Quah TC, Kham SKY, Goh BC, Ariffin H, Yeoh AEJ. Intracellular vincristine levels in lymphoblasts affect treatment outcome in childhood B-lymphoblastic leukaemia: Ma-Spore ALL 2010 study. Br J Clin Pharmacol 2020; 87:1990-1999. [PMID: 33037681 DOI: 10.1111/bcp.14596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/19/2020] [Accepted: 09/27/2020] [Indexed: 11/27/2022] Open
Abstract
AIMS Vincristine (VCR) is a key drug in the successful multidrug chemotherapy for childhood acute lymphoblastic leukaemia (ALL). However, it remains unclear how VCR pharmacokinetics affects its antileukaemic efficacy. The objective of this study is to explore the VCR pharmacokinetic parameters and intracellular VCR levels in an up-front window of Ma-Spore ALL 2010 (MS2010) study. METHODS We randomised 429 children with newly diagnosed ALL to 15-minute vs 3-hour infusion for the first dose of VCR to study if prolonging the first dose of VCR infusion improved response. In a subgroup of 115 B-ALL and 20 T-ALL patients, we performed VCR plasma (n = 135 patients) and intracellular (n = 66 patients) pharmacokinetic studies. The correlations between pharmacokinetic parameters and intracellular VCR levels with early treatment response, final outcome and ABCB1 genotypes were analysed. RESULTS There was no significant difference between 15-minute and 3-hour infusion schedules in median Day 8 peripheral or bone marrow blast response. Plasma VCR pharmacokinetic parameters did not predict outcome. However, in B-ALL, Day 33 minimal residual disease (MRD) negative patients and patients in continuous complete remission had significantly higher median intracellular VCR24h levels (P = .03 and P = .04, respectively). The median VCR24h intracellular levels were similar among the common genetic subtypes of ALL (P = .4). Patients homozygous for wild-type ABCB1 2677GG had significantly higher median intracellular VCR24h (P = .04) than 2677TT. CONCLUSION We showed that in childhood B-ALL, the intracellular VCR24h levels in lymphoblasts affected treatment outcomes. The intracellular VCR24h level was independent of leukaemia subtype but dependent on host ABCB1 G2677T genotype.
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Affiliation(s)
- Nan Jiang
- VIVA-NUS Centre for Translational Research in Acute Leukaemia, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lingzhi Wang
- Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Xiaoqiang Xiang
- Department of Clinical Pharmacy, School of Pharmacy, Fudan University, Shanghai, China
| | - Zhenhua Li
- VIVA-NUS Centre for Translational Research in Acute Leukaemia, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Edwynn Kean Hui Chiew
- VIVA-NUS Centre for Translational Research in Acute Leukaemia, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yok Moi Koo
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - How Sung Lee
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hai Peng Lin
- Sime Darby Medical Centre, Subang Jaya, Malaysia
| | - Ah Moy Tan
- Department of Paediatrics, KK Women's & Cheildren's Hospital, Singapore, Singapore
| | - Thuan Chong Quah
- VIVA-NUS Centre for Translational Research in Acute Leukaemia, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
| | - Shirley Kow Yin Kham
- VIVA-NUS Centre for Translational Research in Acute Leukaemia, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Boon Cher Goh
- Cancer Science Institute of Singapore, National University of Singapore, Singapore
| | - Hany Ariffin
- University of Malaya Cancer Research Institute, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Allen Eng-Juh Yeoh
- VIVA-NUS Centre for Translational Research in Acute Leukaemia, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Cancer Science Institute of Singapore, National University of Singapore, Singapore.,Viva-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
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5
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Schreder M, Knop S. Are triplet therapies really living up to their hype as the “standard of care” for multiple myeloma and what else is needed? Expert Rev Hematol 2019; 12:699-701. [DOI: 10.1080/17474086.2019.1641403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Martin Schreder
- First Department of Medicine, Center for Oncology and Hematology, Wilhelminen Hospital, Vienna, Austria
| | - Stefan Knop
- Department of Internal Medicine II, Division of Hematology and Medical Oncology, University Hospital Wuerzburg, Wuerzburg, Germany
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Wu Q, Liu JR, Huang BH, Zou WY, Gu JL, Chen ML, Kuang LF, Zheng D, Xu DR, Zhou ZH, Wang HH, Su C, Tong XZ, Li J. [Bortezomib-based induction chemotherapy followed by autologous hematopoietic stem cell transplantation and maintenance in 200 patients with multiple myeloma: long-term follow-up results from single center]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:453-459. [PMID: 31340616 PMCID: PMC7342406 DOI: 10.3760/cma.j.issn.0253-2727.2019.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Indexed: 11/05/2022]
Abstract
Objective: To study the efficacy, safety and long-term outcomes of integrated strategy of bortezomib-based induction regimens followed by autologous hematopoietic stem cell (ASCT) and maintenance therapy in Chinese multiple myeloma (MM) patients. Methods: 200 MM patients receiving integrated strategy of bortezomib--based induction regimens followed by ASCT and maintenance therapy were retrospectively and prospectively analyzed from December 1. 2006 to April 30. 2018. Results: The complete remission rates (CR) and better than very good partial remission rates (VGPR) after induction therapy, transplantation and maintenance therapy were respectively 31% and 75.5%, 51.8% and 87.7%,73.6% and 93.4%. There was no difference between 4 cycles and more than 5 cycles induction chemotherapy. The negative rate of MRD detection by flow cytometry was 17.6% and 38.2% respectively after induction and 3 months after transplantation. The negative rate of MRD gradually increased during the maintenance therapy. The success rate of high dose CTX combined with G-CSF mobilization was 95.5% and transplantation related mortality (TRM) was zero. The median time to progress (TTP) was 75.3 months and the median overall survival (OS) was 99.5 months. TTP of patients obtaining CR and negative MRD after induction were longer that those of no CR and positive MRD. TTP and OS of patients receiving triple-drug induction and ASCT in early stage were longer than those of double-drug induction and ASCT in late stage. LDH≥240 U/L, high risk cytogenetics, ISS II+III stage and HBsAg positive were prognostic factors at diagnosis. However, only MRD and high risk cytogenetics were independent prognostic factors after transplantation and maintenance therapy. The clinical characteristics of patients of TTP ≥6 years were listed below: light-chain type M protein, ISS I stage, normal level of hemoglobin and platelet, normal LDH, HBsAg negative, chromosome 17p-negative, good response and sustained good response. Conclusions: Integrated strategy of bortezomib-based induction regimens followed by ASCT and maintenance therapy can significantly improve the short-term and long-term efficacy. The prognostic factors of TTP in different disease stages were different. Response to treatment, especially MRD, played a more important role in prognostic factors.
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Affiliation(s)
- Q Wu
- Department of Hematology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510080, China
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Jose WM, Pavithran K, Ganesan TS. Short-course lenalidomide plus low-dose dexamethasone in the treatment of newly diagnosed multiple myeloma-a single-centre pragmatic study. Curr Oncol 2017; 24:e361-e367. [PMID: 29089806 DOI: 10.3747/co.24.3574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE We assessed response to treatment, toxicity, time to progression, progression-free survival, and overall survival in patients newly diagnosed with multiple myeloma who were ineligible for or unwilling to undergo transplantation and who were treated with a combination of lenalidomide and low-dose dexamethasone for a fixed 6 cycles in a resource-constrained environment. METHODS This pragmatic study, conducted in a single tertiary cancer centre in South India, enrolled patients from May 2009 till April 2011. Treatment included lenalidomide 25 mg daily for 21 days, with dexamethasone 40 mg on days 1, 8, 15, and 22 of a 28-day cycle, for 6 cycles. Response was evaluated after the 3rd and 6th cycles of treatment. All patients were followed for 5 years. RESULTS The study enrolled 51 patients. Median age in the group was 61 years (range: 38-76 years). Immunoglobulin G or A myeloma constituted 70.6% of the diagnoses, and light-chain myeloma constituted 29.4%. Stages i, ii, and iii (International Staging System) disease constituted 21.4%, 28.6%, and 50% of the diagnoses respectively. All patients were transplantation-eligible, but 34 (66.7%) refused for economic reasons. After treatment, 19.6% of the patients achieved a stringent complete response; 35.3%, a complete response; 5.9%, a very good partial response; and 29.4%, a partial response, for an overall response rate of 90.2%. Stable disease was seen in 3.9% of patients, and progressive disease, in 5.9%. Grade 3 or greater nonhematologic and hematologic toxicity occurred in 35.2% and 11.7% of patients respectively. Pulmonary embolism occurred in 1 patient. No patient experienced deep-vein thrombosis or peripheral neuropathy. The median follow-up duration was 66 months. All patients experienced disease progression. Median progression-free survival was 16 months. In 10 patients, re-challenge with lenalidomide and dexamethasone achieved a second complete response. At the time of writing, 19 patients had died. The overall survival rate at 5 years was 62.74%. Median overall survival is not yet reached. CONCLUSIONS In a resource-constrained setting, lenalidomide with low-dose dexamethasone is an effective treatment with acceptable toxicity in patients newly diagnosed with multiple myeloma and not planned for transplantation. Complete responses were significantly more frequent than reported in the Western literature. Occurrence of clinical deep-vein thrombosis was rare, but hyperglycemia was common. An abbreviated course of treatment is suboptimal in multiple myeloma. Maintenance regimens should be advocated.
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Affiliation(s)
- W M Jose
- Department of Medical Oncology and Hematology, Cancer Institute, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Amrita University, Kochi, Kerala, India
| | - K Pavithran
- Department of Medical Oncology and Hematology, Cancer Institute, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Amrita University, Kochi, Kerala, India
| | - T S Ganesan
- Department of Medical Oncology and Hematology, Cancer Institute, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Amrita University, Kochi, Kerala, India
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Abstract
BACKGROUND Multiple myeloma (MM) is the second most common hematologic malignancy, affecting approximately 14,000 new patients in the United State per year. The median overall survival is 5 years, and cure is a realistic goal for only a small minority of patients. METHODS A review of the literature was conducted that focused on treatment strategies for MM involving administration of high doses of chemotherapy followed by autologous or allogeneic hematopoietic stem cell transplant. RESULTS For over three decades, the standard treatment for MM has been a regimen of melphalan and prednisone (MP). Complete responses (CRs) have been rare, and 50% of patients have had disease that was resistant to treatment with MP. Attempts have been made to improve the outcome of MM by administering other combinations of standard doses of chemotherapy, but these treatments are equivalent in terms of overall survival. For patients who are candidates, high-dose therapy followed by autologous stem cell transplantation results in higher CR rates and improved long-term survival compared to treatment with standard doses of chemotherapy alone. While this strategy represents an advance in the treatment of MM, evidence-based reviews indicate that there are a number of issues to consider regarding the induction therapy, the collection of stem cells, and the timing, type, and number of high-dose therapies to use in this type of treatment strategy. CONCLUSIONS Advances have been made in autologous transplantation, allogeneic transplantation, anti-MM agents, and immunotherapy for MM. Combining these different strategies to achieve synergistic responses is an exciting possibility.
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9
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Steinbach M, Richards T, Faiman B. Strategies for Selecting the Optimal Treatment in Newly Diagnosed Multiple Myeloma Patients. Semin Oncol Nurs 2017; 33:254-264. [PMID: 28683956 DOI: 10.1016/j.soncn.2017.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To review the current evidence on strategies for selecting the optimal treatment for newly diagnosed patients with multiple myeloma (MM). DATA SOURCES Journal articles, research reports, state of the science papers, and clinical practice guidelines. CONCLUSION Despite the plethora of drugs to effectively treat MM, the optimal induction regimen for patients with newly diagnosed MM is unknown. Rapid control of the disease, appropriate treatment selection and effective supportive care strategies remain integral to prevention and management of the disease. Strategies for selecting the optimal treatment include considering inherent patient characteristics, frailty, and existing clinical practice guidelines. IMPLICATIONS FOR NURSING PRACTICE Nurses should provide patients with disease- and treatment-related education to enhance patient and caregiver understanding of the disease and treatment options, taking into consideration clinical data and overarching goals of treatment.
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10
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Agarwal MB. Multiple Myeloma: Treatment is Getting Individualized. Indian J Hematol Blood Transfus 2016; 32:3-9. [PMID: 26855501 PMCID: PMC4733675 DOI: 10.1007/s12288-015-0575-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 07/17/2015] [Indexed: 02/02/2023] Open
Abstract
Multiple myeloma (MM) is a heterogeneous disease with varied outcome. The novel agents including two major classes of drugs; the immunomodulatory drugs and the proteasome inhibitors with unprecedented response rates, have replaced conventional chemotherapy. With monoclonal antibodies on the horizon, outcome of this disorder will further improve. Progression in risk stratification systems has made it possible to predict the disease course as well as outcome in myeloma patients with disease categorization into low to high risk. In addition, detection of minimal residual disease by serum free light chain assay, flow cytometry, molecular techniques like polymerase chain reaction and positron emission tomography scan is playing an important role in modifying the treatment. An extensive research in the disease biology has improved our knowledge regarding interplay between myeloma cells and elements of the bone marrow microenvironment which contribute to sustain proliferation and survival as well as de novo drug resistance. Again, insight into the role of genetic and epigenetic interactions in MM has exposed new molecular targets. All these have opened the gateway for novel therapeutic strategies with focus on risk based individualized therapy.
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Affiliation(s)
- M. B. Agarwal
- Department of Haematology, Bombay Hospital Institute of Medical Sciences, Mumbai, India
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11
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Majithia N, Vincent Rajkumar S, Lacy MQ, Buadi FK, Dispenzieri A, Gertz MA, Hayman SR, Dingli D, Kapoor P, Hwa L, Lust JA, Russell SJ, Go RS, Kyle RA, Kumar SK. Outcomes of primary refractory multiple myeloma and the impact of novel therapies. Am J Hematol 2015. [PMID: 26214732 DOI: 10.1002/ajh.24131] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Over the past decade, use of novel agents, including immunomodulatory drugs (IMiDs) and proteasome inhibitors (PIs) has resulted in high response rates and improvement in overall survival (OS) for patients with multiple myeloma (MM); however, the prognostic significance of refractoriness to these agents when used as initial therapy has not been extensively studied. We reviewed the outcomes of 816 consecutive patients treated for MM at our institution since 2006 to evaluate the survival difference between those achieving at least a partial response (PR) to induction therapy and those who were primary refractory. The median OS from start of therapy was significantly shorter for the primary refractory group at 3.6 vs. 7.6 years for the responding patients (P < 0.001). The difference in median OS persisted when only patients receiving a novel agent as part of induction therapy were considered (3.6 vs. 7.9 years, P < 0.001) and in a 4-month landmark analysis (4.2 vs. 7.6 years, P < 0.001). The median OS for patients achieving a complete response (CR), very good partial response (VGPR), PR, or less than PR was not reached (NR), 6.1, 6.4, and 4.2 years from the 4-month landmark, respectively (P < 0.001). The comparatively poor outcomes of patients refractory to induction therapy in the current era of novel agents suggests that this high-risk subpopulation must be further studied for predictors of resistance and, when identified, should be targeted for clinical trials.
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Affiliation(s)
- Neil Majithia
- Department of Internal Medicine; Mayo Clinic; Rochester Minnesota
| | | | - Martha Q. Lacy
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | | | | | - Morie A. Gertz
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | | | - David Dingli
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | | | - Lisa Hwa
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - John A. Lust
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | | | - Ronald S. Go
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Robert A. Kyle
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Shaji K. Kumar
- Division of Hematology; Mayo Clinic; Rochester Minnesota
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Altenburg JD, Farag SS. The potential role of PD0332991 (Palbociclib) in the treatment of multiple myeloma. Expert Opin Investig Drugs 2014; 24:261-71. [DOI: 10.1517/13543784.2015.993753] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jeffrey D Altenburg
- 1Indiana University School of Medicine, Department of Microbiology and Immunology, Indianapolis, IN, USA
| | - Sherif S Farag
- 2Indiana University School of Medicine, Division of Hematology and Oncology, Department of Medicine, Walther Hall R3-C414, 980 West Walnut Street, Indianapolis, IN 46202, USA,
- 3Indiana University School of Medicine, Indiana University Simon Cancer Center, Indianapolis, IN, USA
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13
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Çetin G, Eşkazan AE, Ar MC, Aydın ŞÖ, Ferhanoğlu B, Soysal T, Başlar Z, Aydın Y. Bone-Specific Alkaline Phosphatase Levels among Patients with Multiple Myeloma Receiving Various Therapy Options. Turk J Haematol 2014; 31:374-80. [PMID: 25541654 PMCID: PMC4454052 DOI: 10.4274/tjh.2013.0004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the impact of the different therapy regimens used in multiple myeloma (MM) on bone-specific alkaline phosphatase (BALP) levels. MATERIALS AND METHODS One hundred and thirteen patients with MM were included in the study. Patients were grouped according to the regimens they received, as follows: group 1, melphalan and prednisolone (MP); group 2, vincristine, adriablastin, and dexamethasone (VAD); group 3, thalidomide plus dexamethasone; and group 4, bortezomib plus dexamethasone. BALP levels were measured before treatment and at the third and sixth months of treatment. A fifth group consisted of patients in the post-treatment remission period at study entry (no-treatment group). RESULTS The BALP levels at the third and sixth months of the treatment were significantly higher than the pre-treatment levels in the bortezomib and the no-treatment groups, whereas no significant difference was observed in the MP, VAD, and thalidomide groups. CONCLUSION Considering that BALP is a surrogate marker of bone formation, our study suggests that bortezomib more efficiently leads to the improvement of bone disease in myeloma than other treatment options.
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Affiliation(s)
- Güven Çetin
- Bezmialem Vakıf University Faculty of Medicine, Department of Internal Medicine, Division of Hematology, İstanbul, Turkey. E-ma-il:
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Characteristics and Results of the Treatment of Multiple Myeloma in the Subject under the Age of 65 at the University Hospital of Yopougon in Abidjan, Côte d'Ivoire. Adv Hematol 2014; 2013:583051. [PMID: 24454380 PMCID: PMC3886227 DOI: 10.1155/2013/583051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/07/2013] [Accepted: 12/08/2013] [Indexed: 11/17/2022] Open
Abstract
We retrospectively studied 30 cases of multiple myeloma in patients under the age of 65, diagnosed from 1991 to 2005 in the clinical hematology department of the University Hospital of Yopougon that is a hospital incidence of 2.9 cases/year. The age of patients ranged from 34 to 64 years, with a mean age of 49 years and a sex ratio of 1.73. The professional activity was variable with 3% of radiographers and 10% of farmers. Clinically, the dominant sign was bone pain in 83% of cases. Myeloma was secretory in 93% of cases. It was Ig G-type in 86%, kappa-type in 66% of cases. 86% of patients were anemic, 20% had creatinine >20 mg/L, and 10% had serum calcium >120 mg/L. Geodes were found in 80% of cases. 53% were at stage III of DURIE and SALMON. Complications were infectious (33%), renal (20%), and hemorrhagic (7%). Chemotherapy regimens were VAD (10%), VMCP (30%), and VMCP/VBAP (60%) with 47% of partial responses, 33% of stable disease, and 7% of very good quality partial responses. The outcome developed towards death in 37% and causes of death were renal in 46% of cases. The median survival was only 5.1 months.
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15
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Raje N, Hideshima T, Anderson KC. Therapeutic use of immunomodulatory drugs in the treatment of multiple myeloma. Expert Rev Anticancer Ther 2014; 6:1239-47. [PMID: 17020458 DOI: 10.1586/14737140.6.9.1239] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Immunomodulatory drugs, such as thalidomide, lenalidomide (Revlimid, CC-5013) and actimid (CC-4047), have a broad spectrum of activity and have shown remarkable responses in patients with multiple myeloma and related hematological diseases, such as myelodysplastic syndrome. They are currently being tested in other cancer types. This review will focus on the preclinical and clinical activity of thalidomide and its more potent immunomodulatory derivatives that are used to treat multiple myeloma. They represent a new class of antitumor agents that not only target the tumor cell directly, but also have significant activity within the bone marrow milieu. These agents have shown high responses in all phases of multiple myeloma, including the upfront setting, relapsed refractory stage and also as maintenance therapy for the disease. They have been used in combination with dexamethasone, chemotherapy and, more recently, with other novel agents, such as proteasome inhibitors. Thalidomide and lenalidomide in combination with dexamethasone have recently been approved by the US FDA for the treatment of multiple myeloma.
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Affiliation(s)
- Noopur Raje
- Division of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
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16
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Abstract
The ubiquitin-mediated degradation of proteins in numerous cellular processes, such as turnover and quality control of proteins, cell cycle and apoptosis, transcription and cell signaling, immune response and antigen presentation, and inflammation and development makes the ubiquitin-proteosome systems a very interesting target for various therapeutic interventions. Proteosome inhibitors were first synthesized as tools to probe the function and specificity of this particle's proteolytic activities. Most synthetic inhibitors rely on a peptide base, which mimics a protein substrate, attached at a COOH terminal "warhead." Notable warheads include boronic acids, such as bortezomib and epoxy ketones, such as carfilzomib. A variety of natural products also inhibit the proteosome that are not peptide-based, most notably lactacystin, that is related to NPI-0052, or salinosporamide A, another inhibitor in clinical trials. The possibility that proteosome inhibitors could be drug candidates was considered after studies showed that they induced apoptosis in leukemic cell lines. The first proteasome inhibitor in clinical application, bortezomib showed activity in non-small-cell lung and androgen-independent prostate carcinoma, as well as MM and mantle cell and follicular non-Hodgkin's lymphoma. It is now licensed for the treatment of newly diagnosed as well as relapsed/progressive MM and has had a major impact on the improvement in the treatment of MM in the last few years.
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Affiliation(s)
- Hermann Einsele
- Department of Internal Medicine II, University Hospital Würzburg, Josef-Schneider Straße 2, 97080, Wurzburg, Germany,
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Long-term results in multiple myeloma after high-dose melphalan and autologous transplantation according to response categories in the era of old drugs. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2013; 14:148-54. [PMID: 24417912 DOI: 10.1016/j.clml.2013.11.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Revised: 11/12/2013] [Accepted: 11/17/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND The aim of this study was to investigate the correlation between the long-term prognosis of multiple myeloma (MM) and the quality of response to therapy in a cohort of 173 patients treated with high-dose melphalan (HDM) and autologous transplantation in the era of old drugs. PATIENTS AND METHODS A total of 173 patients with de novo MM who received a transplant between 1994 and 2010 were analyzed. VAD (vincristine, doxorubicin [Adriamycin], dexamethasone) was used as front-line regimen before auto-HPCT. The conditioning was HDM 200 mg/m(2). Patients were evaluated for clinical response using the criteria from the European Group for Blood and Marrow Transplantation, modified to include near complete remission (nCR) and very good partial remission (VGPR). RESULTS The response distribution after transplantation in our series was complete remission (CR) in 33 cases (19%), nearly complete remission (nCR) in 38 cases (22%), VGPR in 30 cases (17%), partial remission (PR) in 65 cases (38%), and stable disease (SD) in 7 cases (4%). Patients were followed for 48 ± 36 months. Median overall survival (OS) was not reached for the CR group. Progression-free survival (PFS) was 122 months for CR, 55 months for nCR, 56 months for VGPR, 32 months for PR, and 22 months for SD. Significant differences in PFS and OS were found between the CR and nCR groups (P = .003 and P = .001, respectively), between the CR and VGPR groups (P = .002 and P = .001, respectively), and between the CR and PR groups (P = .000 and P = .001, respectively). Responses were clustered in 3 main categories, ie, CR, nCR + VGPR + PR, and SD. The respective 10-year PFS and OS values were 58% and 70% for CR, 15% and 18% for nCR + VGPR + PR, and 0% and 0% for SD. CONCLUSION The achievement of depth and prolonged response represents the most important prognostic factor. The relapse rate is low for patients in CR after 10 years of follow-up, possibly signifying a cure.
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Santos ES, Goodman M, Byrnes JJ, Fernandez HF. Thalidomide Effects in the Post-transplantation Setting in Patients with Multiple Myeloma. Hematology 2013; 9:35-9. [PMID: 14965866 DOI: 10.1080/10245330310001652428] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
UNLABELLED Thalidomide recently has been proven to have an impact on plasma cell dyscrasia through multiple mechanisms. Its effects on hematopoietic stem cells both in harvesting and in the immediate post-transplant setting are still unknown. We report on 12 cases (9 males and 3 females), median age 56 years old (range 41-65 years old) who underwent autologous peripheral stem cell transplantation for multiple myeloma and received thalidomide as maintenance therapy post-transplantation. Patients received various cytoreductive therapies prior to stem cell harvest. Eleven patients were in partial remission (PR) and one in complete remission (CR) on entry into the transplant phase of therapy. The median CD34+/kg harvested was 4.7 x 10(6) (range 1.9-55.4 x 10(6) CD34+/kg). All patients received intravenous melphalan 200 mg/m2 as their conditioning regimen. Six of twelve patients attained a CR post-transplant, and six a PR. Thalidomide was started after all patients engrafted post-transplant (absolute neutrophil count >0.5 x 10(9)/l and self-sustained platelet count >20 x 10(9)/l) and following satisfactory resolution of transplant toxicity including mucositis and diarrhea. Thalidomide was initiated at a median of 43 days post-transplant (range 23-138 days). The median leukocyte and platelet counts at the moment of thalidomide initiation were 5.8 x 10(9)/l (range 2.9-8.6 x 10(9)/l) and 196 x 10(9)/l (range 30-351 x 10(9)/l), respectively. Thalidomide was started at 100 mg daily, increasing 100 mg/day/month until reaching a dose of 400 mg/day. One patient failed to tolerate thalidomide due to CNS symptoms and stopped therapy at 12 days. Another patient stopped thalidomide therapy after 71 days, because of severe fatigue secondary to hypothyroidism. The most common adverse effects were constipation (5), rash (4), dry skin (3) and dizziness (3). No grade 3-4 adverse effects were documented. Neutropenia, previously reported as an adverse effect in this setting, was not seen to date in our cohort. All patients attained a CR or PR after transplant and thalidomide maintenance. We have had two relapses during a median follow-up of 68 weeks (range 42-172 weeks). CONCLUSION Thalidomide appears to be a safe drug in the post-transplant setting, perhaps adding to the response achieved post-transplant without major toxicity. Longer follow up and future randomized trials will be needed to validate the role of thalidomide and its long-term effect when used as maintenance therapy in the post-transplant setting.
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Affiliation(s)
- Edgardo S Santos
- Division of Hematology/Oncology, Sylvester Comprehensive Cancer Center, University of Miami, FL 33136, USA
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Decursin and Doxorubicin Are in Synergy for the Induction of Apoptosis via STAT3 and/or mTOR Pathways in Human Multiple Myeloma Cells. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 2013:506324. [PMID: 23818927 PMCID: PMC3684033 DOI: 10.1155/2013/506324] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Revised: 03/16/2013] [Accepted: 04/01/2013] [Indexed: 12/24/2022]
Abstract
Background. Combination cancer therapy is one of the attractive approaches to overcome drug resistance of cancer cells. In the present study, we investigated the synergistic effect of decursin from Angelica gigas and doxorubicin on the induction of apoptosis in three human multiple myeloma cells. Methodology/Principal Findings. Combined treatment of decursin and doxorubicin significantly exerted significant cytotoxicity compared to doxorubicin or decursin in U266, RPMI8226, and MM.1S cells. Furthermore, the combination treatment enhanced the activation of caspase-9 and -3, the cleavage of PARP, and the sub G1 population compared to either drug alone in three multiple myeloma cells. In addition, the combined treatment downregulated the phosphorylation of mTOR and its downstream S6K1 and activated the phosphorylation of ERK in three multiple myeloma cells. Furthermore, the combined treatment reduced mitochondrial membrane potential, suppressed the phosphorylation of JAK2, STAT3, and Src, activated SHP-2, and attenuated the expression of cyclind-D1 and survivin in U266 cells. Conversely, tyrosine phosphatase inhibitor pervanadate reversed STAT3 inactivation and also PARP cleavage and caspase-3 activation induced by combined treatment of doxorubicin and decursin in U266 cells. Conclusions/Significance. Overall, the combination treatment of decursin and doxorubicin can enhance apoptotic activity via mTOR and/or STAT3 signaling pathway in multiple myeloma cells.
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Pozotrigo M, Adel N, Landau H, Lesokhin A, Lendvai N, Chung DJ, Chimento D, Riedel E, Chen X, Reich L, Comenzo R, Giralt S, Hassoun H. Factors impacting stem cell mobilization failure rate and efficiency in multiple myeloma in the era of novel therapies: experience at Memorial Sloan Kettering Cancer Center. Bone Marrow Transplant 2013; 48:1033-9. [PMID: 23334269 DOI: 10.1038/bmt.2012.281] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 11/10/2012] [Accepted: 12/18/2012] [Indexed: 12/22/2022]
Abstract
Thalidomide, lenalidomide and bortezomib have increasingly been incorporated in first-line induction therapies for multiple myeloma. Concerns regarding the impact of these agents, especially lenalidomide, on stem cell mobilization prompted us to re-evaluate the risk factors that impact mobilization, including exposure to novel induction regimens. Among 317 patients who proceeded to stem cell collection after induction therapy between 2000 and 2009, the rate of mobilization failure, defined as the inability to collect 5 × 10(6) CD34+ cells/kg following the first collection attempt, was 13%. By multivariate analysis, independent risk factors associated with mobilization failure included older age (P=0.04), lower platelet count (P=0.002) and use of single-agent G-CSF for mobilization (P<0.0001). When considering for outcome measurement stem cell collection efficiency measured by the number of CD34+ cells yielded per pheresis performed during first collection attempt, lower platelet count, use of single-agent G-CSF and older age were also associated with lower efficiency. In this population mobilized mostly with cyclophosphamide and G-CSF, the use of lenalidomide during induction was not associated with a lower stem cell collection efficiency by multivariate analysis. The data support the current International Multiple Myeloma Working Group guidelines recommending the use of cyclophosphamide and G-CSF based mobilization for patients previously exposed to lenalidomide.
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Affiliation(s)
- M Pozotrigo
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Kobayashi T, Kuroda J, Fuchida SI, Murakami S, Hatsuse M, Okano A, Iwai T, Tsutsumi Y, Kamitsuji Y, Akaogi T, Kawata-Iida E, Shimizu D, Uchiyama H, Matsumoto Y, Horiike S, Nakao M, Takahashi R, Kaneko H, Uoshima N, Kobayashi Y, Shimazaki C, Taniwaki M. The response to second-line induction with bortezomib and dexamethasone is predictive of long-term outcomes prior to high-dose chemotherapy with autologous stem cell transplantation for multiple myeloma. Intern Med 2013; 52:961-8. [PMID: 23648714 DOI: 10.2169/internalmedicine.52.9385] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE We retrospectively investigated the efficacy and predictive factors for the treatment outcomes of bortezomib plus dexamethasone (BD) as second-line induction therapy prior to high-dose chemotherapy supported by autologous stem cell transplantation (HDT/ASCT) in multiple myeloma (MM) patients. METHODS Sixty-six transplant eligible MM patients treated by the Kyoto Clinical Hematology Study Group between 2006 and 2011 were investigated. Conventional induction chemotherapy, including vincristine, doxorubicin and dexamethasone (VAD) and high-dose dexamethasone (HDD), was used as first-line induction therapy in all patients, seven (10.6%) of whom attained a very good partial response (VGPR). Of the 59 patients who did not attain VGPR with VAD or HDD, 33 were given BD as second-line induction therapy prior to HDT/ASCT. RESULTS Patients not treated with BD induction showed an overall response rate (ORR, i.e., better than partial response) of 85.3% after induction therapy, while the ORR of patients treated with BD induction improved from 42.4% after conventional induction therapy to 84.8% after BD. The overall survival (OS) and progression-free survival (PFS) of patients not treated with BD induction were not significantly influenced by the response to induction therapy. Among the patients treated with BD, failure in attaining VGPR prior to ASCT was associated with a significantly shorter PFS and it also tended to show a shorter OS, while the disease stage and achievement of a complete response after HDT/ASCT had no impact on OS or PFS. CONCLUSION The achievement of at least VGPR with second-line BD induction therapy is a prerequisite for attaining longer OS and PFS after HDT/ASCT.
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Affiliation(s)
- Tsutomu Kobayashi
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Japan.
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Lee HS, Kim YS, Kim K, Kim JS, Kim HJ, Min CK, Suh C, Eom HS, Yoon SS, Lee JH, Kim MK, Kim SH, Bae SH, Mun YC, Jo DY, Chung JS. Early response to bortezomib combined chemotherapy can help predict survival in patients with multiple myeloma who are ineligible for stem cell transplantation. J Korean Med Sci 2013; 28:80-6. [PMID: 23341716 PMCID: PMC3546109 DOI: 10.3346/jkms.2013.28.1.80] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 10/24/2012] [Indexed: 11/24/2022] Open
Abstract
Novel agents to treat multiple myeloma (MM) have increased complete respone (CR) rates compared with conventional chemotherapy, and the quality of the response to treatment has been correlated with survival. The purpose of our study was to show how of early response to bortezomib combined chemotherapy influences survival in patients with newly diagnosed MM who are ineligible for stem cell transplantation. We assessed patient responses to at least four cycles of bortezomib using the International Myeloma Working Group response criteria. The endpoints were comparisons of progression free survival (PFS) and overall survival (OS) between early good response group (A group) and poor response group (B group). We retrospectively analyzed data from 129 patients registered by the Korean Multiple Myeloma Working Party, a nationwide registration of MM patients. The 3 yr PFS for the A and B groups was 55.6% and 18.4%, respectively (P < 0.001). The 3 yr OS for the A and B groups was 65.3% and 52.9%, respectively (P = 0.078). The early response to at least four cycle of bortezomib before next chemotherapy may help predict PFS in patients with MM who are ineligible stem cell transplantation.
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Affiliation(s)
- Ho Sup Lee
- Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Yang Soo Kim
- Department of Internal Medicine, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Kihyun Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Jung Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Chang-Ki Min
- Department of Internal Medicine, St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Cheolwon Suh
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeon-Seok Eom
- Hematology-Oncology Clinic, National Cancer Center, Goyang, Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jae Hoon Lee
- Department of Internal Medicine, Gachon University Gil Hospital, Incheon, Korea
| | - Min Kyong Kim
- Department of Hemato-Oncology, Yeungnam University College of Medicine, Daegu, Korea
| | - Sung-Hyun Kim
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Sung Hwa Bae
- Division of Hematology-Oncology, Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu, Korea
| | - Yeung-Chul Mun
- Division of Hematology and Oncology, Department of Internal Medicine, Ewha Woman's University School of Medicine, Seoul, Korea
| | - Deog Yeon Jo
- Department of Hematology/Oncology, Chungnam National University Hospital, Daejeon, Korea
| | - Joo-Seop Chung
- Department of Hematology-Oncology, Busan National Cancer Center, Pusan National University Hospital Medical Research Institute, Busan, Korea
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Jakubowiak A. Management strategies for relapsed/refractory multiple myeloma: current clinical perspectives. Semin Hematol 2012; 49 Suppl 1:S16-32. [PMID: 22727389 DOI: 10.1053/j.seminhematol.2012.05.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In the last decade, the introduction of novel agents including the immunomodulatory drugs thalidomide and lenalidomide, and the first-in-class proteasome inhibitor bortezomib, has dramatically improved clinical outcome in patients with relapsed/refractory multiple myeloma (MM) compared to conventional chemotherapy alone. Although combination treatment approaches with traditional cytotoxic agents and novel agents have led to response rates as high as 85% in patients with relapsed/refractory disease, not all patients will respond to established novel agents, and even those who do respond will ultimately relapse or become refractory to currently available regimens. There is no generally accepted standard treatment for patients with relapsed/refractory disease; however, both disease-related (eg, quality and duration of response to previous therapies and the aggressiveness of the relapse) and patient-related (eg, preexisting toxicities, comorbid conditions, quality of life, age, and performance status) factors should be considered when selecting the best treatment option. This article will review up-to-date approaches for managing patients with relapsed/refractory MM, including the efficacy and safety of established novel agents, the use of adjunctive/supportive care, and strategies for tailored treatment.
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Monoclonal gammopathy of renal significance: when MGUS is no longer undetermined or insignificant. Blood 2012; 120:4292-5. [PMID: 23047823 DOI: 10.1182/blood-2012-07-445304] [Citation(s) in RCA: 332] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Multiple myeloma is the most frequent monoclonal gammopathy to involve the kidney; however, a growing number of kidney diseases associated with other monoclonal gammopathies are being recognized. Although many histopathologic patterns exist, they are all distinguished by the monoclonal immunoglobulin (or component) deposits. The hematologic disorder in these patients is more consistent with monoclonal gammopathy of undetermined significance (MGUS) than with multiple myeloma. Unfortunately, due to the limitations of the current diagnostic schema, they are frequently diagnosed as MGUS. Because treatment is not recommended for MGUS, appropriate therapy is commonly withheld. In addition to end-stage renal disease, the persistence of the monoclonal gammopathy is associated with high rates of recurrence after kidney transplantation. Preservation and restoration of kidney function are possible with successful treatment targeting the responsible clone. Achievement of hematologic complete response has been shown to prevent recurrence after kidney transplantation. There is a need for a term that properly conveys the pathologic nature of these diseases. We think the term monoclonal gammopathy of renal significance is most helpful to indicate a causal relationship between the monoclonal gammopathy and the renal damage and because the significance of the monoclonal gammopathy is no longer undetermined.
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Bringhen S, Gay F, Pautasso C, Cerrato C, Boccadoro M, Palumbo A. Evaluation of the pharmacokinetics, preclinical, and clinical efficacy of lenalidomide for the treatment of multiple myeloma. Expert Opin Drug Metab Toxicol 2012; 8:1209-22. [DOI: 10.1517/17425255.2012.712685] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Sonneveld P, Schmidt-Wolf IGH, van der Holt B, El Jarari L, Bertsch U, Salwender H, Zweegman S, Vellenga E, Broyl A, Blau IW, Weisel KC, Wittebol S, Bos GMJ, Stevens-Kroef M, Scheid C, Pfreundschuh M, Hose D, Jauch A, van der Velde H, Raymakers R, Schaafsma MR, Kersten MJ, van Marwijk-Kooy M, Duehrsen U, Lindemann W, Wijermans PW, Lokhorst HM, Goldschmidt HM. Bortezomib induction and maintenance treatment in patients with newly diagnosed multiple myeloma: results of the randomized phase III HOVON-65/ GMMG-HD4 trial. J Clin Oncol 2012; 30:2946-55. [PMID: 22802322 DOI: 10.1200/jco.2011.39.6820] [Citation(s) in RCA: 609] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
PURPOSE We investigated whether bortezomib during induction and maintenance improves survival in newly diagnosed multiple myeloma (MM). PATIENTS AND METHODS In all, 827 eligible patients with newly diagnosed symptomatic MM were randomly assigned to receive induction therapy with vincristine, doxorubicin, and dexamethasone (VAD) or bortezomib, doxorubicin, and dexamethasone (PAD) followed by high-dose melphalan and autologous stem-cell transplantation. Maintenance consisted of thalidomide 50 mg (VAD) once per day or bortezomib 1.3 mg/m(2) (PAD) once every 2 weeks for 2 years. The primary analysis was progression-free survival (PFS) adjusted for International Staging System (ISS) stage. RESULTS Complete response (CR), including near CR, was superior after PAD induction (15% v 31%; P < .001) and bortezomib maintenance (34% v 49%; P < .001). After a median follow-up of 41 months, PFS was superior in the PAD arm (median of 28 months v 35 months; hazard ratio [HR], 0.75; 95% CI, 0.62 to 0.90; P = .002). In multivariate analysis, overall survival (OS) was better in the PAD arm (HR, 0.77; 95% CI, 0.60 to 1.00; P = .049). In high-risk patients presenting with increased creatinine more than 2 mg/dL, bortezomib significantly improved PFS from a median of 13 months to 30 months (HR, 0.45; 95% CI, 0.26 to 0.78; P = .004) and OS from a median of 21 months to 54 months (HR, 0.33; 95% CI, 0.16 to 0.65; P < .001). A benefit was also observed in patients with deletion 17p13 (median PFS, 12 v 22 months; HR, 0.47; 95% CI, 0.26 to 0.86; P = .01; median OS, 24 months v not reached at 54 months; HR, 0.36; 95% CI, 0.18 to 0.74; P = .003). CONCLUSION Bortezomib during induction and maintenance improves CR and achieves superior PFS and OS.
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Curability of multiple myeloma. BONE MARROW RESEARCH 2012; 2012:916479. [PMID: 22675638 PMCID: PMC3366198 DOI: 10.1155/2012/916479] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 02/23/2012] [Indexed: 11/18/2022]
Abstract
Among 792 patients with multiple myeloma treated from 1987 to 2010 and assessed after 18 months, there were 167 patients with complete remission. For those 60 patients treated between 1987–1998 and with long followup, the latest relapse occurred after 11.8 years, so that 13 patients have remained in sustained complete remission for longer than 12 years (range 12–22 years). These results suggest that 3% of all patients treated during that period may be cured of multiple myeloma. In addition to immunofixation, more sensitive techniques for the detection of residual disease should be applied more consistently in patients with apparent complete remission in order to identify those with potential cure.
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Lee JH, Lee JH, Kim DY, Kim SD, Choi Y, Kang YA, Seol M, Lee KH. Two cycles of the PS-341/bortezomib, adriamycin, and dexamethasone combination followed by autologous hematopoietic cell transplantation in newly diagnosed multiple myeloma patients. Eur J Haematol 2012; 88:478-84. [DOI: 10.1111/j.1600-0609.2012.01771.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chen RA, Tu Y, Cao Y, Liu L, Liang Y. Bortezomib-Dexamethasone or Vincristine-Doxorubicin-Dexamethasone as Induction Therapy Followed by Thalidomide as Maintenance Therapy in Untreated Multiple Myeloma Patients. J Int Med Res 2011; 39:1975-84. [PMID: 22118002 DOI: 10.1177/147323001103900544] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
This randomized, retrospective study evaluated the effect of thalidomide combined with bortezomib-dexamethasone (TBD) or vincristine-doxorubicin-dexamethasone (T-VAD) on 46 patients with multiple myeloma. Newly diagnosed patients were randomly allocated to receive TBD ( n = 24) or T-VAD ( n = 22). The high-quality response rate (complete response plus very good partial response) was 62.5% in the TBD group and 45.4% for T-VAD. The complete response rate was 29.2% for TBD and 13.6% for T-VAD. Overall survival at 2 and 3 years, respectively, was 91.7% and 62.5% for TBD versus 86.4% and 54.5% for T-VAD. Most of the toxic effects of treatment were well tolerated. Both regimens were effective in the treatment of newly diagnosed multiple myeloma patients. Further studies are required to determine the role of thalidomide in these two regimens.
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Affiliation(s)
- RA Chen
- Department of Haematology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Y Tu
- Department of Emergency, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Y Cao
- Department of Emergency, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - L Liu
- Department of Haematology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Y Liang
- Department of Haematology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
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Berenson JR, Yellin O, Chen CS, Patel R, Bessudo A, Boccia RV, Yang HH, Vescio R, Yung E, Mapes R, Eades B, Hilger JD, Wirtschafter E, Hilger J, Nassir Y, Swift RA. A modified regimen of pegylated liposomal doxorubicin, bortezomib and dexamethasone (DVD) is effective and well tolerated for previously untreated multiple myeloma patients. Br J Haematol 2011; 155:580-7. [DOI: 10.1111/j.1365-2141.2011.08884.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sequential vincristine, adriamycin, dexamethasone (VAD) followed by bortezomib, thalidomide, dexamethasone (VTD) as induction, followed by high-dose therapy with autologous stem cell transplant and consolidation therapy with bortezomib for newly diagnosed multiple myeloma: results of a phase II trial. Ann Hematol 2011; 91:249-56. [PMID: 21789621 DOI: 10.1007/s00277-011-1298-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Accepted: 07/11/2011] [Indexed: 10/18/2022]
Abstract
Incorporation of novel agents has resulted in an improved response rate and reduced side effects in multiple myeloma. This has prompted combining novel agents in induction chemotherapy in patients with newly diagnosed multiple myeloma. Our patients received 2 cycles of vincristine, adriamycin, dexamethasone (VAD) and then 2 cycles of bortezomib, thalidomide, dexamethasone (VTD) chemotherapy as an induction treatment. Subsequently, autologous stem cell transplantation was performed, and bortezomib was administered as a consolidation therapy. Seventy-one patients were enrolled, and 65 were evaluable for response. After 2 cycles of VAD, the overall response rate was 69%. After VTD, the response rate improved to 97% with a complete response (CR) and near CR rate of 27%. Importantly, patients with cytogenetics, having poor prognostic features, all responded after VTD. Autologous stem cells were successfully collected in all 58 patients with a median CD34+ cell count of 7.12 × 10(6)/kg (range, 1.94-44.7 × 10(6)/kg), except in 1 patient (2%). After ASCT, 36 patients completed bortezomib maintenance with a combined CR and near CR rate approaching 75%. Median time to response was rapid (1.6 months). With a median follow-up duration of 52.7 months, the median TTP was 29.4 months and median OS was not reached. Toxicities proved manageable. In conclusion, sequential VAD and VTD induction therapy in patients with newly diagnosed multiple myeloma was active with manageable toxicity and excellent stem cell yields. The incorporation of bortezomib as a consolidation therapy improved the clinical outcome with the expense of rather frequent development of peripheral neuropathy.
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Palumbo A, Attal M, Roussel M. Shifts in the therapeutic paradigm for patients newly diagnosed with multiple myeloma: maintenance therapy and overall survival. Clin Cancer Res 2011; 17:1253-63. [PMID: 21411441 DOI: 10.1158/1078-0432.ccr-10-1925] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High-dose therapy (HDT) with autologous stem cell transplantation (ASCT) is the standard of care for eligible newly diagnosed multiple myeloma (MM) patients. Several randomized studies showed a survival advantage for patients undergoing transplantation, compared with conventional chemotherapy. Introduction of new drugs in this setting has markedly increased survival rates within the last 10 years. Efforts to further improve response rates and survival in those patients are still needed, mainly by increasing the depth of tumor reduction and the duration of response through more effective induction, consolidation, and maintenance therapies. Nevertheless, this approach is currently challenged by the promising results of long-term treatment with novel agents. Recent data suggest that the upfront combination of a proteasome inhibitor plus 1 immunomodulatory compound (IMiD) is highly effective. The combination of bortezomib, thalidomide, and dexamethasone (VTD) has proven to be highly effective as a frontline treatment and is significantly superior to vincristine, doxorubicin, and dexamethasone (VAD) or thalidomide and dexamethasone (Thal-Dex) before and after ASCT with a very manageable toxicity pattern. The most promising 3-drug association might be bortezomib, lenalidomide, and dexamethasone (VRD). Adjunction of a 4th drug has not proven to be more efficient. In patients not eligible for ASCT, the introduction of novel agents has changed the management of multiple myeloma. The combinations of melphalan, prednisone, and thalidomide and of bortezomib, melphalan, and prednisone have shown improved progression-free survival and overall survival in comparison with melphalan and prednisone alone. Melphalan, prednisone, and thalidomide and bortezomib, melphalan, and prednisone are now the new standards of care for elderly patients. Preliminary results also support the role of the combination of melphalan, prednisone, and lenalidomide followed by maintenance therapy with lenalidomide in the treatment of elderly patients. Physicians now have a wider variety of treatment options to tailor the most appropriate and efficacious treatment according to their patients' characteristics.
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Affiliation(s)
- Antonio Palumbo
- Myeloma Unit, Division of Hematology, University of Turin, Turin, Italy.
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Zhang S, Farag SS. From cell biology to therapy: ENMD-2076 in the treatment of multiple myeloma. Expert Opin Investig Drugs 2011; 20:1015-28. [DOI: 10.1517/13543784.2011.584869] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Bird JM, Owen RG, D'Sa S, Snowden JA, Pratt G, Ashcroft J, Yong K, Cook G, Feyler S, Davies F, Morgan G, Cavenagh J, Low E, Behrens J. Guidelines for the diagnosis and management of multiple myeloma 2011. Br J Haematol 2011; 154:32-75. [PMID: 21569004 DOI: 10.1111/j.1365-2141.2011.08573.x] [Citation(s) in RCA: 206] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Jennifer M Bird
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
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Richardson PG, Mitsiades CS, Laubach JP, Lonial S, Chanan-Khan AA, Anderson KC. Inhibition of heat shock protein 90 (HSP90) as a therapeutic strategy for the treatment of myeloma and other cancers. Br J Haematol 2011; 152:367-79. [PMID: 21219297 DOI: 10.1111/j.1365-2141.2010.08360.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Heat shock protein 90 (HSP90) is a molecular chaperone that is induced in response to cellular stress and stabilizes client proteins involved in cell cycle control and proliferative/anti-apoptotic signalling. HSP90 is overexpressed in a range of cancers, and may contribute to tumour cell survival by stabilizing aberrant signalling proteins and by interfering with apoptosis. Tanespimycin, an HSP90 inhibitor, reduces tumour cell survival in vitro. In multiple myeloma (MM), HSP90 inhibition affects multiple client proteins that contribute to tumour cell survival, including the IGF1 receptor and the IL-6 receptor, and elements of the PI3/Akt, STAT3, and MAPK signalling pathways. HSP90 inhibition also abrogates the protective effect of bone marrow stromal cells and inhibits angiogenesis and osteoclastogenesis. Tanespimycin acts synergistically with the proteasome inhibitor bortezomib in MM cells and tumour explants, possibly reducing their ability to resist bortezomib-induced stress to the endoplasmic reticulum. The combination of tanespimycin and bortezomib has demonstrated significant and durable responses with acceptable toxicity in a phase I/II study in patients with relapsed and relapsed/refractory MM. HSP90 inhibition is a promising strategy in MM especially in combination with bortezomib; additional studies will further evaluate optimal dosings of candidate drugs and schedules, as well as confirm efficacy in comparative phase III trials.
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Patra HK, Dasgupta AK, Sarkar S, Biswas I, Chattopadhyay A. Dual role of nanoparticles as drug carrier and drug. Cancer Nanotechnol 2011; 2:37-47. [PMID: 26069483 PMCID: PMC4451630 DOI: 10.1007/s12645-010-0011-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Accepted: 12/07/2010] [Indexed: 01/13/2023] Open
Abstract
The conventional chemotherapeutic agents used in the treatment of human malignancies are directed nonspecifically against both malignant and nonmalignant cells, often limiting their efficacy with having serious side effects. Recent development of drug delivery vehicles has opened up the possibility of targeted drug delivery systems with the potential of achieving maximum efficacy with minimal toxicity. The possibility of using a nanomaterial as a combinational drug component is intuitively evident as it would compensate the toxicity level by enhancing drug delivery efficiency. Additionally, cell-specific cytotoxicity (reported earlier by our group) of the nanovehicle itself may potentiate a more effective targeted cell killing. In this paper, we explore the possibility of using gold nanoparticles playing the dual role of an anticancer agent and a carrier of a chemotherapeutic drug. This is demonstrated using vincristine sulfate (VS), salt of an alkaloid often used in the treatment of multiple myeloma (MM), and U266 as a test MM cell line. The drug VS shows the expected G2-M-phase arrest of cells. Notably, bare gold nanoparticle shows arrest of the S phase cells that may be particularly important in case of slow-growing malignancies like MM where most of the cells remain in G1 phase of the cell cycle. The VS conjugated gold retains the activity of both gold nanoparticle and VS leading to a synergistic rise of the apoptotic cell population.
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Affiliation(s)
- Hirak Kumar Patra
- />Department of Biochemistry, University of Calcutta, 35 Ballygunge Circular Road, Kolkata, 700019 India
| | - Anjan Kr. Dasgupta
- />Department of Biochemistry, University of Calcutta, 35 Ballygunge Circular Road, Kolkata, 700019 India
| | - Sounik Sarkar
- />Department of Biochemistry, University of Calcutta, 35 Ballygunge Circular Road, Kolkata, 700019 India
- />Institute of Haematology and Transfusion Medicine, MCH Building (2nd floor), Medical College 88 College Street, Kolkata, 700073 India
| | - Indranil Biswas
- />Institute of Haematology and Transfusion Medicine, MCH Building (2nd floor), Medical College 88 College Street, Kolkata, 700073 India
| | - Arnab Chattopadhyay
- />Institute of Haematology and Transfusion Medicine, MCH Building (2nd floor), Medical College 88 College Street, Kolkata, 700073 India
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Roussel M, Facon T, Moreau P, Harousseau JL, Attal M. Firstline treatment and maintenance in newly diagnosed multiple myeloma patients. Recent Results Cancer Res 2011; 183:189-206. [PMID: 21509686 DOI: 10.1007/978-3-540-85772-3_9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
High dose therapy (HDT) with autologous stem cell transplantation (ASCT) is the standard of care for eligible newly diagnosed MM patients. Several randomized studies demonstrated a survival advantage for patients undergoing transplantation, compared with conventional chemotherapy. Introduction of new drugs in this setting have markedly increased survival rates within the last 10 years. Efforts to further improve response rates and survival in those patients are still needed, mainly by increasing the depth of tumor reduction and the duration of response through more effective induction, consolidation and maintenance therapies. Nevertheless, this approach is currently challenged by the promising results of long-term treatment with novel agents. Recent data suggest that the upfront combination of a proteasome inhibitor plus one immunomodulatory drug (IMiD) is highly effective. The most promising 3-drug association might be Bortezomib, Lenalidomide and dexamethasone (VRD). Adjunction of a 4th drug is not proven to be more efficient. Consolidation and maintenance therapies are emerging in all trials with great results. For elderly patients, or not eligible for ASCT, the introduction of novel agents has also changed the management of the disease. Melphalan-prednisone-thalidomide and bortezomib-melphalan-prednisone are the two standards of care. Current trials are challenging the role of alkylators in the frontline setting. Maintenance therapy is also undergoing evaluation.
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Maginn EN, Browne PV, Hayden P, Vandenberghe E, MacDonagh B, Evans P, Goodyer M, Tewari P, Campiani G, Butini S, Williams DC, Zisterer DM, Lawler MP, McElligott AM. PBOX-15, a novel microtubule targeting agent, induces apoptosis, upregulates death receptors, and potentiates TRAIL-mediated apoptosis in multiple myeloma cells. Br J Cancer 2010; 104:281-9. [PMID: 21179037 PMCID: PMC3031893 DOI: 10.1038/sj.bjc.6606035] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: In recent years, much progress has been made in the treatment of multiple myeloma. However, a major limitation of existing chemotherapeutic drugs is the eventual emergence of resistance; hence, the development of novel agents with new mechanisms of action is pertinent. Here, we describe the activity and mechanism of action of pyrrolo-1,5-benzoxazepine-15 (PBOX-15), a novel microtubule-targeting agent, in multiple myeloma cells. Methods: The anti-myeloma activity of PBOX-15 was assessed using NCI-H929, KMS11, RPMI8226, and U266 cell lines, and primary myeloma cells. Cell cycle distribution, apoptosis, cytochrome c release, and mitochondrial inner membrane depolarisation were analysed by flow cytometry; gene expression analysis was carried out using TaqMan Low Density Arrays; and expression of caspase-8 and Bcl-2 family of proteins was assessed by western blot analysis. Results: Pyrrolo-1,5-benzoxazepine-15 induced apoptosis in ex vivo myeloma cells and in myeloma cell lines. Death receptor genes were upregulated in both NCI-H929 and U266 cell lines, which displayed the highest and lowest apoptotic responses, respectively, following treatment with PBOX-15. The largest increase was detected for the death receptor 5 (DR5) gene, and cotreatment of both cell lines with tumour necrosis factor-related apoptosis-inducing ligand (TRAIL), the DR5 ligand, potentiated the apoptotic response. In NCI-H929 cells, PBOX-15-induced apoptosis was shown to be caspase-8 dependent, with independent activation of extrinsic and intrinsic apoptotic pathways. A caspase-8-dependent decrease in expression of BimEL preceded downregulation of other Bcl-2 proteins (Bid, Bcl-2, Mcl-1) in PBOX-15-treated NCI-H929 cells. Conclusion: PBOX-15 induces apoptosis and potentiates TRAIL-induced cell death in multiple myeloma cells. Thus, PBOX-15 represents a promising agent, with a distinct mechanism of action, for the treatment of this malignancy.
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Affiliation(s)
- E N Maginn
- John Durkan Leukaemia Laboratories, Institute of Molecular Medicine, Trinity College Dublin, St James's Hospital, Dublin 8, Ireland
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Isoda A, Matsumoto M, Nakahashi H, Mawatari M, Manaka A, Sawamura M. Reduced risk of bacterial infection in multiple myeloma patients with VAD regimen without intermittent high-dose dexamethasone. Int J Hematol 2010; 93:59-65. [PMID: 21161620 DOI: 10.1007/s12185-010-0735-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2010] [Revised: 11/02/2010] [Accepted: 11/22/2010] [Indexed: 11/25/2022]
Abstract
Vincristine-adriamycin-dexamethasone (VAD) regimen with intermittent high-dose dexamethasone (HD) has been used as primary chemotherapy for multiple myeloma (MM) patients who are candidates for high-dose therapy or present with renal failure. However, dexamethasone increases the risk of infection in MM patients. We retrospectively evaluated treatment efficacy and infectious events in MM patients undergoing VAD with or without HD. Seventy-seven consecutive patients who received VAD without HD (n = 37) or VAD-HD (n = 40) at our institution were assessed. Characteristics of patients and VAD regimens were retrospectively analyzed to detect correlations with the incidence of infections. During 218 VAD cycles, 48 infectious episodes were documented in 39 patients. Of these, 32 episodes in 26 patients were severe (grade ≥ 3). By analyzing each patient, VAD-HD was associated with risk of all-grade and severe bacterial infection, while International Staging System stage ≥ 2 was independently correlated with severe bacterial infection. Response rates after two cycles were comparable between the 2 VAD regimens. In conclusion, risk of infection is lower in VAD without HD than in VAD-HD, and the clinical response is equivalent. VAD-HD should thus be avoided for MM patients with high risk of infection.
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Affiliation(s)
- Atsushi Isoda
- Department of Hematology, National Hospital Organization Nishigunma National Hospital, 2854 Kanai, Shibukawa, Gunma 377-8511, Japan.
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Li SD, Wang YF, Qi JY, Qiu LG. Clinical Features of Bone Complications and Prognostic Value of Bone Lesions Detected by X-ray Skeletal Survey in Previously Untreated Patients with Multiple Myeloma. Indian J Hematol Blood Transfus 2010; 26:83-8. [PMID: 21886388 DOI: 10.1007/s12288-010-0033-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Accepted: 09/05/2010] [Indexed: 11/30/2022] Open
Abstract
Multiple myeloma is usually associated with the presence of lytic bone lesions. We reviewed the clinical and laboratory features of patients with newly diagnosed myeloma bone disease and evaluated the prognostic significance of different X-ray image patterns in symptomatic MM patients. We retrospectively reviewed 260 patients with newly diagnosed MM. X-ray image patterns of patients were correlated with hematologic parameters, therapeutic reaction and patient survival. Patients with the X-ray imaging pattern of grade 2-4 had significantly higher marrow plasma cells levels, marrow CD138(+) D38(+) cell percentage, ECOG performance score, and serum IL-6 level than grade 0-1. Univariate analysis demonstrated that skeletal lytic changes associated with rapid progression. There is a high incidence of myeloma bone disease (MBD) in patients of MM in China. Patients of extensive bone lesions have more severe alterations in hematologic parameters than do those without bone lesions and severe bone lesions is an important adverse prognostic factor associated with a short TTP.
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Lin CK, Sung YC. Newly diagnosed multiple myeloma in Taiwan: the evolution of therapy, stem cell transplantation and new treatment agents. Hematol Oncol Stem Cell Ther 2010; 2:385-93. [PMID: 20139051 DOI: 10.1016/s1658-3876(09)50006-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Multiple myeloma is a clonal plasma cell dyscrasia with clinical heterogeneity. As of now, two key questions need to be answered before starting to treat a newly diagnosed myeloma patient. One is whether the patient is a candidate for high-dose chemotherapy with stem cell support and the other is risk stratification. As novel therapeutics have emerged, it is increasingly important to introduce a risk-adapted approach. The heterogeneity of the disease is established, for the most part, by disease biology, predominantly genetics. Cytogenetic analysis by either banding technique or fluorescent in situ hybridization is able to identify high-risk subpopulations. The new international staging system based on beta2-microglobulin and albumin levels in serum is also very helpful in defining the high-risk group (stage 3). This group of patients may not respond well to high-dose chemotherapy and require early introduction of newer treatments such as the bortezomib-containing regimen. The main factor in determining the eligibility for stem cell transplants is age. Based on the current literature and situation in Taiwan, we suggest stem cell transplantation if the patient is younger than 55 years of age. Each case should be considered individually if the age of the patient is between 55 and 70 years. Finally, we have also reviewed the status and the treatment of multiple myeloma in Taiwan. Fortunately, there has been an improvement in awareness, diagnosis and treatment. Cytogenetic studies have been applied in risk evaluations, but are limited in a few centers due to lack of availability. With the exception of the agent lenalidomide, new novel agents are available for treating of myeloma in Taiwan.
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Kfir-Erenfeld S, Sionov RV, Spokoini R, Cohen O, Yefenof E. Protein kinase networks regulating glucocorticoid-induced apoptosis of hematopoietic cancer cells: fundamental aspects and practical considerations. Leuk Lymphoma 2010; 51:1968-2005. [PMID: 20849387 DOI: 10.3109/10428194.2010.506570] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Glucocorticoids (GCs) are integral components in the treatment protocols of acute lymphoblastic leukemia, multiple myeloma, and non-Hodgkin lymphoma owing to their ability to induce apoptosis of these malignant cells. Resistance to GC therapy is associated with poor prognosis. Although they have been used in clinics for decades, the signal transduction pathways involved in GC-induced apoptosis have only partly been resolved. Accumulating evidence shows that this cell death process is mediated by a communication between nuclear GR affecting gene transcription of pro-apoptotic genes such as Bim, mitochondrial GR affecting the physiology of the mitochondria, and the protein kinase glycogen synthase kinase-3 (GSK3), which interacts with Bim following exposure to GCs. Prevention of Bim up-regulation, mitochondrial GR translocation, and/or GSK3 activation are common causes leading to GC therapy failure. Various protein kinases positively regulating the pro-survival Src-PI3K-Akt-mTOR and Raf-Ras-MEK-ERK signal cascades have been shown to be activated in malignant leukemic cells and antagonize GC-induced apoptosis by inhibiting GSK3 activation and Bim expression. Targeting these protein kinases has proven effective in sensitizing GR-positive malignant lymphoid cells to GC-induced apoptosis. Thus, intervening with the pro-survival kinase network in GC-resistant cells should be a good means of improving GC therapy of hematopoietic malignancies.
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Affiliation(s)
- Shlomit Kfir-Erenfeld
- The Lautenberg Center of Immunology and Cancer Research, Hebrew University-Hadassah Medical School, Jerusalem, Israel
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Gay F, Rajkumar SV, Coleman M, Kumar S, Mark T, Dispenzieri A, Pearse R, Gertz MA, Leonard J, Lacy MQ, Chen-Kiang S, Roy V, Jayabalan DS, Lust JA, Witzig TE, Fonseca R, Kyle RA, Greipp PR, Stewart AK, Niesvizky R. Clarithromycin (Biaxin)-lenalidomide-low-dose dexamethasone (BiRd) versus lenalidomide-low-dose dexamethasone (Rd) for newly diagnosed myeloma. Am J Hematol 2010; 85:664-9. [PMID: 20645430 DOI: 10.1002/ajh.21777] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The objective of this case-matched study was to compare the efficacy and toxicity of the addition of clarithromycin (Biaxin) to lenalidomide/low-dose dexamethasone (BiRd) vs. lenalidomide/low-dose dexamethasone (Rd) for newly diagnosed myeloma. Data from 72 patients treated at the New York Presbyterian Hospital-Cornell Medical Center were retrospectively compared with an equal number of matched pair mates selected among patients seen at the Mayo Clinic who received Rd. Case matching was blinded and was performed according to age, gender, and transplant status. On intention-to-treat analysis, complete response (45.8% vs. 13.9%, P < 0.001) and very-good-partial-response or better (73.6% vs. 33.3%, P < 0.001) were significantly higher with BiRd. Time-to-progression (median 48.3 vs. 27.5 months, P = 0.071), and progression-free survival (median 48.3 vs. 27.5 months, P = 0.044) were higher with BiRd. There was a trend toward better OS with BiRd (3-year OS: 89.7% vs. 73.0%, P = 0.170). Main grade 3-4 toxicities of BiRd were hematological, in particular thrombocytopenia (23.6% vs. 8.3%, P = 0.012). Infections (16.7% vs. 9.7%, P = 0.218) and dermatological toxicity (12.5% vs. 4.2%, P = 0.129) were higher with Rd. Results of this case-matched analysis suggest that there is significant additive value when clarithromycin is added to Rd. Randomized phase III trials are needed to confirm these results.
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Affiliation(s)
- Francesca Gay
- Division of Hematology, Department of Internal Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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Dabrowska D, Gore C, Griffiths S, Mudzingwa M, Varaday S. Anaesthetic management of a pregnant patient with multiple myeloma. Int J Obstet Anesth 2010; 19:336-9. [DOI: 10.1016/j.ijoa.2010.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Revised: 09/25/2009] [Accepted: 03/10/2010] [Indexed: 10/19/2022]
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Zhao F, Chen Y, Zeng LL, Li R, Zeng R, Wen L, Liu Y, Zhang C. Effects of triptolide on RIZ1 expression, proliferation, and apoptosis in multiple myeloma U266 cells. Acta Pharmacol Sin 2010; 31:733-40. [PMID: 20523343 DOI: 10.1038/aps.2010.49] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIM To investigate the effects of triptolide on proliferation and apoptosis as well as on the expression of RIZ1 in the human multiple myeloma cell line U266 in vitro. METHODS The effect of triptolide on the growth of U266 cells was studied by MTT assay. Apoptosis was detected by Hoechst 33258 staining and Annexin V/PI double-labeled flow cytometry, and caspase-3 mRNA was measured by RT-PCR. Western blotting, flow cytometry and RT-PCR were used to assess the expression of RIZ1, and the location and expression of H3K9me1 were detected by confocal microscopy and Western blotting. RESULTS Triptolide significantly inhibited the proliferation of U266 cells in a time- and concentration-dependent manner (the IC(50) value for a 24-h exposure was 157.19+/-0.38 nmol/L). Triptolide induced typical apoptotic morphological changes. Triptolide 40, 80, and 160 nmol/L treatment induced significant caspase-3-dependent apoptosis compared with control group (10.5%+/-1.23%, 37.9%+/-2.45%, and 40.5%+/-2.30% vs 3.8%+/-1.98%, P<0.05). Compared with peripheral blood monocular cells (PBMC) from healthy donors, the protein expression of RIZ1 in U266 cells was relatively low, but the mRNA and protein expression of RIZ1 were strikingly increased by triptolide in a concentration-dependent manner. Triptolide increased the protein expression of RIZ1 and RIZ1 methylates histone H3 lysine 9 in U266 cells. CONCLUSION Triptolide increased the protein expression of RIZ1, inhibited the proliferation, and induced caspase-dependent apoptosis in U266 cells.
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Management of disease- and treatment-related complications in patients with multiple myeloma. Med Oncol 2010; 27 Suppl 1:S43-52. [DOI: 10.1007/s12032-010-9542-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Corso A, Barbarano L, Mangiacavalli S, Spriano M, Alessandrino EP, Cafro AM, Pascutto C, Varettoni M, Bernasconi P, Grillo G, Carella AM, Montalbetti L, Lazzarino M, Morra E. Bortezomib plus dexamethasone can improve stem cell collection and overcome the need for additional chemotherapy before autologous transplant in patients with myeloma. Leuk Lymphoma 2010; 51:236-42. [PMID: 20001242 DOI: 10.3109/10428190903452826] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The aim of this phase II trial was to investigate the efficacy of bortezomib plus dexamethasone (Vel-Dex) as induction therapy in patients with multiple myeloma (MM) and to define the role of intensification before transplantation. Fifty-seven patients were treated with four courses of Vel-Dex, two cycles of dexamethasone, cyclophosphamide, etoposide and cisplatin (DCEP), and a single autologous transplant. Fourteen patients (25%) went off-study: seven after Vel-Dex, seven after DCEP. All patients yielded high numbers of stem cells (median CD34+ cells 7.5 x 106/kg); 54 of the 57 patients (94%) collected > or =4 x 106/kg CD34+ cells, 60% with a single leukapheresis. The overall response rate (ORR) after Vel-Dex was 86% (70% had a very good partial response [VGPR] or better) regardless of cytogenetic abnormalities and International Staging System stage (ISS). The response at the end of the two DCEP cycles remained unchanged in 35 patients (70%), worsened in 15 (20%), and improved in 5 (10%). Because of the consistent drop-out, the ORR in intention-to-treat analysis decreased significantly from 86% after Vel-Dex to 76% after DCEP, and 73% after transplantation. However, when considering the subset of 43 patients who completed the program, the ORR was 96% (complete response 39%, VGPR 41%, partial response 16%). In conclusion, Vel-Dex produces high response rates, improves stem cell collection, and overcomes the need for intensification before autologous transplantation.
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Affiliation(s)
- Alessandro Corso
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.
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Fung HC, Nathan S, Maciejewski JJ. Induction chemotherapy before autologous stem cell transplantation for symptomatic plasma cell myeloma - does it matter? Clin Pharmacol 2010; 2:71-5. [PMID: 22291488 PMCID: PMC3262376 DOI: 10.2147/cpaa.s6258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Autologous stem cell transplantation is the preferred treatment option for younger patients with symptomatic plasma cell myeloma. Most patients with newly diagnosed plasma cell myeloma receive 3-4 cycles of induction chemotherapy to achieve a level of disease control before proceeding to stem cell transplant. The ideal induction regimen for transplant-eligible patients shall allow more patients to proceed with transplant, rapidly and effectively control the disease, reverse disease-related complications, avoid early death, and is associated with minimal acute and long-term toxicities. Because of the concerns of potential damages to hematopoietic stem cells, alkylating agent regimens, specifically melphalan, are usually avoided for induction in transplant-eligible patients. Before the advance of immunomodulatory agents (IMiD) and proteasome inhibitors, the combination of vincristine, adriamycin, and dexamethasone (VAD) and variants were the most commonly used induction regimens. Recent reports as discussed in this review suggests that VAD is no longer the induction chemotherapy of choice for transplant eligible patients. Newer regimens incorporating IMiD and/or proteasome inhibitor into the induction regimen improve response rates and progression-free survival before and after the transplant and are evolving as the treatment of choice. Here, we review the available data on these newer induction regimens and to evaluate the potential impacts on the patient outcomes.
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Affiliation(s)
- Henry C Fung
- Coleman Foundation Blood and Marrow Transplantation Program, Section of Bone Marrow Transplant and Cell Therapy, Division of Hematology/Oncology/Stem Cell Transplant, Rush University Medical Center, Chicago, Illinois, USA
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Chanan-Khan AA, Giralt S. Importance of achieving a complete response in multiple myeloma, and the impact of novel agents. J Clin Oncol 2010; 28:2612-24. [PMID: 20385994 DOI: 10.1200/jco.2009.25.4250] [Citation(s) in RCA: 164] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The goal of treatment for multiple myeloma (MM) is to improve patients' long-term outcomes. One important factor that has been associated with prolonged progression-free and overall survival is the quality of response to treatment, particularly achievement of a complete response (CR). There is extensive evidence from clinical studies in the transplant setting in first-line MM demonstrating that CR or maximal response post-transplant is significantly associated with prolonged progression-free and overall survival, with some studies demonstrating a similar association with postinduction response. Supportive evidence is also available from studies in the nontransplant and relapsed settings. With the introduction of bortezomib, thalidomide, and lenalidomide, higher rates of CR are being achieved in both first-line and relapsed MM compared with previous chemotherapeutic approaches, thereby potentially improving long-term outcomes. While standard CR by established response criteria has been shown to have differential prognostic impact compared with lesser responses, increasingly sensitive analytic techniques are now being explored to define more stringent degrees of CR or elimination of minimal residual disease (MRD), including multiparameter flow cytometry and polymerase chain reaction. Demonstrating eradication of MRD by these techniques has already been shown to predict for improved outcomes. Here, we review the prognostic significance of achieving CR in MM and highlight the importance of CR as an increasingly realizable goal at all stages of treatment. We discuss clinical management issues and provide recommendations relevant to practicing oncologists, such as the routine use of sensitive techniques for assessment of disease status to inform evidence-based decisions on optimal patient management.
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Affiliation(s)
- Asher A Chanan-Khan
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY 14263, USA.
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